There are two major types of skin reactions associated with hand hygiene. The first and most common type includes symptoms that can vary from quite mild to debilitating, including dryness, irritation, itching, and even cracking and bleeding. This array of symptoms is referred to as irritant contact dermatitis. The second type of skin reaction, allergic contact dermatitis, is rare and represents an allergy to some ingredient in a hand hygiene product. Symptoms of allergic contact dermatitis can also range from mild and localized to severe and generalized. In its most serious form, allergic contact dermatitis may be associated with respiratory distress and other symptoms of anaphylaxis. Therefore it is sometimes difficult to differentiate between the two conditions. HCWs with skin reactions or complaints related to hand hygiene should have access to an appropriate referral service.
14.1. Frequency and pathophysiology of irritant contact dermatitis
Irritant contact dermatitis is extremely common among nurses, ranging in prevalence surveys from 25% to 55%, and as many as 85% relate a history of having skin problems.572,573 Frequent and repeated use of hand hygiene products, particularly soaps and other detergents, is an important cause of chronic irritant contact dermatitis among HCWs.574 Cutaneous adverse reaction was infrequent among HCWs (13/2750 exposed HCWs) exposed to an alcohol-based preparation containing chlorhexidine gluconate and skin emollient during a hand hygiene culture change, multimodal programme;548 it represented one cutaneous adverse event per 72 years of HCW exposure. The potential of detergents to cause skin irritation varies considerably and can be reduced by the addition of humectants. Irritation associated with antimicrobial soaps may be attributable to the antimicrobial agent or to other ingredients of the formulation. Affected HCWs often complain of a feeling of dryness or burning, skin that feels “rough”, and erythema, scaling or fissures. An example of a hand skin self-assessment tool is given in Appendix 3. In addition, two similar protocols to assess skin tolerance and product acceptability by HCWs after use of an alcohol-based handrub are included in the Implementation Toolkit of the WHO Multimodal Hand Hygiene Improvement Strategy.575 The method is based on: 1) objective evaluation of dermal tolerance by an investigator using a validated scale; 2) subjective evaluation by the HCW of his/her own skin conditions and of the product characteristics. The simpler protocol is meant to be used to assess a single product in the short term (3–5 days after use) and in the longer term (1 month after use); it is easy to implement under ordinary conditions. A more investigational protocol has been designed to make a fast-track comparison of two or more products using a double-blind, randomized, cross-over methodology.504
Hand hygiene products damage the skin by causing denaturation of stratum corneum proteins, changes in intercellular lipids (either depletion or reorganization of lipid moieties), decreased corneocyte cohesion and decreased stratum corneum water-binding capacity.574,576 Among these, the main concern is the depletion of the lipid barrier that may be consequent to contact with lipid-emulsifying detergents and lipid-dissolving alcohols.577 Frequent handwashing leads to progressive depletion of surface lipids with resulting deeper action of detergents into the superficial skin layers. During dry seasons and in individuals with dry skin, this lipid depletion occurs more quickly.577 Damage to the skin also changes skin flora, resulting in more frequent colonization by staphylococci and Gram-negative bacilli.79,219
Although alcohols are safer than detergents,262 they can cause dryness and skin irritation.48,578 The lipid-dissolving effect of alcohols is inversely related to their concentration,577 and ethanol tends to be less irritating than n-propanol or isopropanol.578 Numerous reports confirm that alcohol-based formulations are well tolerated and often associated with better acceptability and tolerance than other hand hygiene products.504,548,579–584
In general, irritant contact dermatitis is more commonly reported with iodophors220 Other antiseptic agents that may cause irritant contact dermatitis, in order of decreasing frequency, include chlorhexidine, chloroxylenol, triclosan, and alcohol-based products. Skin that is damaged by repeated exposure to detergents may be more susceptible to irritation by all types of hand antisepsis formulations, including alcohol-based preparations.585 Graham and colleagues reported low rates of cutaneous adverse reactions to an alcohol-based handrub (isopropyl alcohol 70%) formulation containing chlorhexidine (0.5%) with emollient.548
Information regarding the irritancy potential of commercially prepared hand hygiene products, which is often determined by measuring the transepidermal water loss of persons using the preparation, may be available from the manufacturer. Other factors that may contribute to dermatitis associated with frequent hand cleansing include using hot water for handwashing, low relative humidity (most common in winter months in the northern hemisphere), failure to use supplementary hand lotion or cream, and perhaps the quality of paper towels.586,587 Shear forces associated with wearing or removing gloves and allergy to latex proteins may also contribute to dermatitis of the hands of HCWs.577
In a recent study conducted among ICU HCWs, the short-term skin tolerability and acceptability of the WHO-recommended alcohol-based formulations (see Section 12) were significantly higher than those of a reference product.504 Risk factors identified for skin alteration following handrub use were male sex, fair and very fair skin, and skin alteration before use.
14.2. Allergic contact dermatitis related to hand hygiene products
Allergic reactions to products applied to the skin (contact allergy) may present as delayed type reactions (allergic contact dermatitis) or less commonly as immediate reactions (contact urticaria). The most common causes of contact allergies are fragrances and preservatives, with emulsifiers being less common.588–591 Liquid soaps, hand lotion, ointments or creams used by HCWs may contain ingredients that cause contact allergies.589,590
Allergic reactions to antiseptic agents including QAC, iodine or iodophors, chlorhexidine, triclosan, chloroxylenol and alcohols285,330,332,339,588,592–597 have been reported, as well as possible toxicity in relation to dermal absorption of products.598,599 Allergic contact dermatitis attributable to alcohol-based handrubs is very uncommon. Surveillance at a large hospital in Switzerland where a commercial alcohol-based handrub has been used for more than 10 years failed to identify a single case of documented allergy to the product.484 In late 2001, a Freedom of Information Request for data in the FDA’s Adverse Event Reporting System regarding adverse reactions to popular alcohol-based handrubs in the USA yielded only one reported case of an erythematous rash reaction attributed to such a product (J. M. Boyce, personal communication). However, with the increasing use of such products by HCWs, it is likely that true allergic reactions to such products will occasionally be encountered. There are a few reports of allergic dermatitis resulting from contact with ethyl alcohol600–602 and one report of ethanol-related contact urticaria syndrome.331 More recently, Cimiotti and colleagues reported adverse reactions associated with an alcohol-based handrub preparation. In most cases, nurses who had symptoms were able to resume use of the product after a brief hiatus.332 This study raises the alert for possible skin reactions to alcohol-based handrub preparations. In contrast, in a double-blind trial by Kampf and colleagues582 of 27 persons with atopic dermatitis, there were no significant differences in the tolerability of alcohol-based handrubs when compared with normal controls.
Allergic reactions to alcohol-based formulations may represent true allergy to the alcohol, or allergy to an impurity or aldehyde metabolite, or allergy to another product constituent.330 Allergic contact dermatitis or immediate contact urticarial reactions may be caused by ethanol or isopropanol.330 Allergic reactions may be caused by compounds that may be present as inactive ingredients in alcohol-based handrubs, including fragrances, benzyl alcohol, stearyl or isostearyl alcohol, phenoxyethanol, myristyl alcohol, propylene glycol, parabens, or benzalkonium chloride.330,491,588,603–606
14.3. Methods to reduce adverse effects of agents
There are three primary strategies for minimizing hand hygiene-related irritant contact dermatitis among HCWs: selecting less irritating hand hygiene products; avoiding certain practices that increase the risk of skin irritation; and using moisturizing skin care products following hand cleansing.607
14.3.1. Selecting less irritating products
Because HCWs must clean hands frequently, it is important for health-care facilities to provide products that are both efficacious and as safe as possible for the skin. The tendency of products to cause skin irritation and dryness is a major factor influencing their acceptance and ultimate use by HCWs.137,264,608–611 For example, concern about the drying effects of alcohol was a major cause of poor acceptance of alcohol-based handrubs in hospitals.313,612 Although many hospitals have provided HCWs with plain soaps in the hope of minimizing dermatitis, frequent use of such products has been associated with even greater skin damage, dryness and irritation than some antiseptic preparations.220,262,264 One strategy for reducing exposure of HCWs to irritating soaps and detergents is to promote the use of alcohol-based handrubs containing humectants. Several studies have demonstrated that such products are tolerated better by HCWs and are associated with a better skin condition when compared with either plain or antimicrobial soap.60,262,264,326,329,486,577,613,614 With rubs, the shorter time required for hand antisepsis may increase acceptability and compliance.615 In settings where the water supply is unsafe, waterless hand antisepsis presents additional advantages over soap and water.616
14.3.2. Reducing skin irritation
Certain hand hygiene practices can increase the risk of skin irritation and should be avoided. For example, washing hands regularly with soap and water immediately before or after using an alcohol-based product is not only unnecessary, but may lead to dermatitis.617 Additionally, donning gloves while hands are still wet from either washing or applying alcohol increases the risk of skin irritation. For these reasons, HCWs should be reminded not to wash their hands before or after applying alcohol and to allow their hands to dry completely before donning gloves. A recent study demonstrated that HCW education regarding proper skin care management was effective in preventing occupational skin disorders.618 No product, however, is free of potential risk. Hence, it is usually necessary to provide an alternative for use by individuals with sensitivity or reactions to the hand hygiene product available in the institution.
14.3.3. Use of moisturizing skin care products
The effects of hand hygiene products on skin vary considerably, depending upon factors such as the weather and environmental conditions. For example, in tropical countries and during the summer months in temperate climates, the skin remains more moisturized than in cold, dry environments. The effects of products also vary by skin type. In one recent study, nurses with darker skin were rated as having significantly healthier skin and less skin irritation than nurses with light skin, both by their own self-assessment as well as by observer rating.619 Results of a prevalence survey of 282 Chinese hospital nurses suggested that hand dermatitis was less common among this group when compared with those in other parts of the world.620 In contrast, the reported prevalence of dermatitis was 53.3% in a survey of 860 Japanese nurses, and the use of hand cream was associated with a 50% reduction.621 The need for moisturizing products will thus vary across health-care settings, geographical locations and respective climate conditions, and individuals.
For HCWs at risk of irritant contact dermatitis or other adverse reactions to hand hygiene products, additional skin moisturizing may be needed. Hand lotions and creams often contain humectants, fats, and oils that increase skin hydration and replace altered or depleted skin lipids that contribute to the barrier function of the skin.576,622 Several controlled trials have shown that regular use of such products can help prevent and treat irritant contact dermatitis caused by hand hygiene products.623–627
Importantly, in a trial by McCormick and colleagues,624 improved skin condition resulting from the frequent and scheduled use of an oil-containing lotion led to a 50% increase in hand cleansing frequency among HCWs. These investigators emphasized the need to educate HCWs regarding the value of regular, frequent use of hand-care products. However, most hand moisturizing agents are not sterile and thus may easily become contaminated; they have been associated also with outbreaks in the neonatal ICU setting.628 In particular, if the lotion is poured from a large bottle into smaller bottles, the smaller containers should be washed and disinfected between uses and not topped up.
Recently, barrier creams have been marketed for the prevention of hand hygiene-related irritant contact dermatitis. Such products are absorbed into the superficial layers of the epidermis and are designed to form a protective layer that is not removed by standard hand cleansing. Evidence of the efficacy of such products, however, is equivocal.623,624,629 Furthermore, such products are expensive, so their use in health-care settings, particularly when resources are limited, cannot be recommended at present. Whether the use of basic, oil-containing products, not specifically manufactured for hand skin protection, would have similar efficacy as currently available manufactured agents remains to be determined.
Frequent wearing of gloves can increase the risk of skin problems. In a study among healthy volunteers, when a moisturizer was applied prior to wearing occlusive gloves, there was a statistically significant improvement in skin hydration.630 More recently, an examination glove coated with aloe vera resulted in improved skin integrity and decreased erythema in 30 women with occupational dry skin.631 Nevertheless, such products cannot yet be recommended as field trials, larger sample sizes, and cost analyses are needed.
In addition to evaluating the efficacy and acceptability of hand-care products, product selection committees should inquire about potential deleterious effects that oil-containing products may have on the integrity of rubber gloves and on the efficacy of antiseptic agents used in the facility,204,632 as well as the fact that, as previously mentioned, most of these products are not sterile and can easily become contaminated.
